Serum Biomarkers of a Pro-Neuroinflammatory State May Define the Pre-Operative Risk for Postoperative Delirium in Spine Surgery.

Advances in spine surgery enable technically safe interventions in older patients with disabling spine disease, yet postoperative delirium (POD) poses a serious risk for postoperative recovery. This study investigates biomarkers of pro-neuroinflammatory states that may help objectively define the pre-operative risk for POD. This study enrolled patients aged ≥60 scheduled for elective spine surgery under general anesthesia. Biomarkers for a pro-neuroinflammatory state included S100 calcium-binding protein ß (S100ß), brain-derived neurotrophic factor (BDNF), Gasdermin D, and the soluble ectodomain of the triggering receptor expressed on myeloid cells 2 (sTREM2). Postoperative changes of Interleukin-6 (IL-6), Interleukin-1ß (IL-1ß), and C-reactive protein (CRP) were assessed as markers of systemic inflammation preoperatively, intraoperatively, and early postoperatively (up to 48 h). Patients with POD (n = 19, 75.7 ± 5.8 years) had higher pre-operative levels of sTREM2 (128.2 ± 69.4 pg/mL vs. 97.2 ± 52.0 pg/mL, p = 0.049) and Gasdermin D (2.9 ± 1.6 pg/mL vs. 2.1 ± 1.4 pg/mL, p = 0.29) than those without POD (n = 25, 75.6 ± 5.1 years). STREM2 was additionally a predictor for POD (OR = 1.01/(pg/mL) [1.00-1.03], p = 0.05), moderated by IL-6 (Wald-χ2 = 4.06, p = 0.04). Patients with POD additionally showed a significant increase in IL-6, IL-1ß, and S100ß levels on the first postoperative day. This study identified higher levels of sTREM2 and Gasdermin D as potential markers of a pro-neuroinflammatory state that predisposes to the development of POD. Future studies should confirm these results in a larger cohort and determine their potential as an objective biomarker to inform delirium prevention strategies.

Tracheal airway pressure in tracheostomy tube capping trials: an experimental study.

BACKGROUND: Tracheostomy tube capping is a commonly used test to determine if the tracheostomy tube can be removed. The success of the capping trial depends on the patient's ability to maintain sufficient spontaneous breathing with an occluded tracheostomy tube. The impact of an occluded tracheotomy tube on airway resistance is currently unknown. The aim of this study was to investigate tracheal pressure during capping or stoma button insertion and potential determinants concerning cuff. METHODS: Eight cuffed and uncuffed tracheostomy tubes and three stoma buttons of various manufacturers and sizes were inserted into the trachea model. Cuffs were completely deflated or contained atmospheric pressure. The trachea was ventilated bidirectional with a respirator in volume-controlled mode and volume flows 15-60 L/min. Tracheal pressure drop during inspiration as a parameter of pressure required to move gas through the airway was measured. RESULTS: Tracheal pressure drops occurred linearly or irregularly during capping trials to a maximum of 4.2 kPa at flow rates of 60 L/min for atmospheric pressure cuffs. In tracheostomy tubes with completely deflated cuffs, pressure drop in the trachea reaches a maximum of 3.4 kPa at a flow rate of 60 L/min. For tracheostomy tubes with cuff smaller inner or outer diameters do not regularly result in lower tracheal pressure drop. The pressure drop varies between different tracheostomy tubes depending on the manufacturer. In cuffed tracheostomy tubes, we observed three phenomena: sail-like positioning, folding over, and tightening of the cuff during flow. The maximum tracheal pressure drop during stoma button insertion reaches 0.014 kPa. CONCLUSIONS: The cuff is a central element for the pressure drop in the airway and thus airway resistance during spontaneous translaryngeal breathing with a capped TT. Complete deflation reduces the pressure drop in the trachea. Due to deformation of the cuff, measured pressures are irregular as the volume flow is increased. Incomplete deflated cuffs and material characteristics of tracheostomy tubes and cuffs in addition to anatomical and clinical variables may cause unsuccessful capping trials due to increased airway resistance. All stoma buttons showed that pressure drop and thus airway resistance due to stoma buttons has no clinical relevance.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation.

BACKGROUND: The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. METHODS: One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. RESULTS: Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). CONCLUSION: The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Computerized 4-choice reaction time test for the measurement of psychomotor recovery after general anesthesia.

The recovery of patients after general anesthesia is usually estimated by using clinical scores. Since there is a lack of objective methods for assessing psychomotor recovery, the aim of this study was to evaluate three psychological tests for this purpose. Patients, scheduled for ambulatory gynecological surgery, underwent 3 standard psychological tests before (T1), 15 min after the surgery (T2) and on discharge from the recovery room (T3). The tests used were Wechsler memory scale (test 1, working memory capacity), d2-test (test 2, concentration endurance) and computer-based 4-choice-reaction time (4CRT, test 3, reaction time) as well as Postanesthesia Discharge Scoring System (PADSS). The same test battery was used in healthy female volunteers, all test results were compared at the different time points. In 109 patients, working memory capacity and concentration (tests 1 and 2) decreased, the reaction time (test 3) was prolonged at T2 in comparison with T1 and T3 (P < 0.01). PADSS increased from 8 (T2) to 10 (T3) (medians, P < 0.001). Fifty-seven healthy volunteers demonstrated a practice effect in all 3 tests through the course of the study (P <0.01). 4CRT test had shortest duration and enabled computerized data processing. All three tests objectively assess the recovery of psychomotor function in patients after general anesthesia, the computer-based 4CRT seems to be the most convenient for the clinical routine.

Treating Therapy-Resistant Headache After Aneurysmal Subarachnoid Hemorrhage with Acupuncture.

INTRODUCTION: Subarachnoid haemorrhage (SAH) is usually associated with severe headache, whereas the options of pharmacological analgesia are restricted. Acupuncture is a promising method in treatment of headaches associated with meningeal sensitivity or irritation, such as migraine or post-dural puncture headache. CASE REPORT: We report on 3 patients, who suffered severe headache due to aneurysmal SAH, and received acupuncture when pharmacological measures were exhausted. After acupuncture treatment all patients reported at least 50% pain reduction and could stop or reduce analgesics without side effects. DISCUSSION: Acupuncture may be an effective pain treatment method in patients suffering from headache due to SAH. Randomized trials using acupuncture as an add-on to standard analgesic therapy would help evaluate the role of acupuncture for this purpose.

Effects of Electrical Transcutaneous Vagus Nerve Stimulation on the Perceived Intensity of Repetitive Painful Heat Stimuli: A Blinded Placebo- and Sham-Controlled Randomized Crossover Investigation.

BACKGROUND: Transcutaneous vagus nerve stimulation (TVNS) is a promising treatment for acute and chronic pain. However, experimental studies yielded controversial results. We examined if TVNS reduces the perceived intensity of repetitive painful heat stimulation and temporal summation of pain (TSP) in healthy volunteers in comparison with placebo and sham stimulation, as well as no intervention. METHODS: In 4 sessions, 90 heat pulse stimuli at individual pain tolerance temperature were applied to the ventral forearm of 49 healthy volunteers (25 women) using a Contact Heat Evoked Potential Stimulator thermode (Medoc, Ramat Yishai, Israel). Pain intensity was assessed with verbal ratings on a numeric pain scale (0-100) at every tenth heat pulse. After the first session in which pain intensities without intervention were evaluated, participants completed 3 sessions in a single-blinded randomized crossover manner: (1) sham stimulation applied at the earlobes, (2) placebo stimulation (inactive device), or (3) TVNS applied at the cymbas conchae. Primary data were analyzed using analysis of variance for repeated measures and t test for paired samples. RESULTS: Pain intensity decreased during all interventions as compared to no intervention (ηp = 0.22, P < .001; mean difference TVNS versus no intervention 9.5; 95% confidence interval [CI], 3.6-15.4; P < .001). Hypoalgesic effect of TVNS was better than that of placebo and sham in men before the onset of TSP (mean differences for TVNS versus placebo 6.2; 95% CI, 0.2-12.1; TVNS versus sham 6.2; 95% CI, 0.2-12.1; P < .05). In women, TSP response under TVNS was decreased if compared to no intervention (median difference, 7.5; 95% CI, 3.5-15.0; P = .003). CONCLUSIONS: TVNS, placebo, and sham stimulation exerted comparable effects under experimental heat pain stimulation. Only in male participants, TVNS was superior to sham and placebo conditions in the reduction of heat pain before the onset of TSP.

Remote Effects of Electromagnetic Millimeter Waves on Experimentally Induced Cold Pain: A Double-Blinded Crossover Investigation in Healthy Volunteers.

BACKGROUND: The hypoalgesic effect of electromagnetic millimeter waves (MW) is well studied in animal model; however, the results of human research are controversial. The aim of this study was to evaluate the effects of various frequency ranges of MW on hypoalgesia using the cold pressor test (CPT). METHODS: Experimental pain was induced using standardized CPT protocols in 20 healthy male volunteers. The skin of the lower part of sternum was exposed to MW with a frequency of 42.25 GHz (active generator); MW within 50-75 GHz frequency range (noise generator); or an inactive MW device (placebo generator) in a random crossover double-blinded manner. Pain threshold, measured using the CPT, was the primary outcome. Other CPT parameters, heart rate, blood pressure, incidence of subjective sensations (paresthesia) during exposure, as well as quality of volunteers' blinding were also recorded. The end points of the condition with exposure to 42.25 GHz, were compared with baseline; exposure to noise 50-75 GHz; and placebo generators. RESULTS: Pain threshold increased during exposure to the 42.25 GHz generator when compared with baseline: median difference (MD), 1.97 seconds (95% confidence interval [CI], 0.35-3.73) and noise generator: MD, 1.27 seconds (95% CI, 0.05-2.33) but not compared with the placebo generator. Time to onset of cold and increasing pain sensations as well as diastolic blood pressure increased under the exposure to the 42.25 GHz generator when compared with baseline and noise generator. Other outcome measures were comparable among the study conditions. CONCLUSIONS: We were able to partially confirm the previously suggested hypoalgesic effects of low-intensity electromagnetic MW. However, the effect was indistinguishable from the placebo condition in our investigation.

Feasibility and safety of dilatational tracheotomy using the rigid endoscope: a multicenter study.

BACKGROUND: Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED). METHODS: In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant. RESULTS: PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%). CONCLUSION: The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible.

The Impact of Integrated Multidisciplinary Palliative Care Program on Symptoms in Patients at the Palliative Care Ward-An Audit and a Protocol of Prospective Controlled Investigation.

An integrated multidisciplinary palliative care (IMPC) program is a promising tool to improve symptom control in patients at the end of life. The aim was to study the feasibility of the IMPC program in patients at the palliative care (PC) ward. A retrospective audit, using the extended Edmonton Symptom Assessment Scale (ESAS), was conducted on the PC ward of the university hospital. Consecutive patients who were admitted for the IMPC program during 1 year were considered. One hundred forty-eight cases (93% with underlying cancer) were analyzed. The intensity of pain levels, nausea, vomiting, shortness of breath, and sleep disorders decreased at least by 50% ( P < .0001) during the 13 (median) days of IMPC. Integrated multidisciplinary PC program was associated with symptom improvements in patients at the PC ward. The information generated supports sample size calculation for a prospective controlled trial.

Effects of auricular stimulation on weight- and obesity-related parameters: a systematic review and meta-analysis of randomized controlled clinical trials.

Background: Over the last three decades, the number of randomized controlled trials (RCTs) using stimulation of auricular vagal sensory nerves by means of electrical stimulation, auricular acupuncture, or acupressure to support weight loss has increased markedly. This systematic review focuses on the effects of auricular stimulation (AS) on anthropometric parameters and obesity-related blood chemistry. Methods and analysis: The following databases were searched until November 2021: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. Data collection and analysis were conducted by two reviewers independently. Quality and risk assessment of included studies was performed using the risk of bias tool of the Cochrane Handbook, and the meta-analysis of the effect of the most frequently assessed biomarkers was conducted using the statistical software RevMan. Results: The full texts of 1,274 studies were screened; 22 contained data on obesity-related outcomes, and 15 trials with 1,333 patients were included in the meta-analysis. The overall quality of the included trials was moderate. AS significantly reduced body mass index (BMI) (mean difference (MD) = -0.38 BMI points, 95% CI (-0.55 to -0.22), p < 0.0001), weight (MD = -0.66 kg, 95% CI (-1.12 to -0.20), p = 0.005), waist circumference (MD = -1.44 cm, 95% CI (-2.69 to -0.20), p = 0.02), leptin, insulin, and HOMA insulin resistance compared to controls. No significant reduction was found in body fat, hip circumference, ratio of waist/hip circumference, cholesterol, LDL, triglycerides, adiponectin, ghrelin, and glucose levels. The AS was safe throughout the trials, with only minor adverse reactions. Conclusion: The study results suggest that a reduction of weight and BMI can be achieved by AS in obese patients; however, the size of the effect does not appear to be of clinical relevance. The effects might be underestimated due to active sham trials. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021231885.

Methods of administering superimposed high-frequency jet ventilation and the associated risk for aspiration in a model of tracheal bleeding.

BACKGROUND: To determine the suitability of different superimposed high-frequency jet ventilation (SHFJV) application methods during tracheal bleeding. OBJECTIVE: To determine the effect of SHFJV on the aspiration of blood during tracheal bleeding. METHODS: A test lung was ventilated using SHFJV via a rigid endoscope, a jet laryngoscope and a 4-lumen jet catheter. Packed red blood cells (PRBCs) were injected into the artificial trachea caudally to the rigid endoscope and jet laryngoscope ventilation, and both caudally and cranially during ventilation via the 4-lumen jet catheter, and the migration of PRBCs during ventilation was studied using continuous video recording. RESULTS: Migration of blood into the lower respiratory tract did not occur during SHFJV via the rigid endoscope and jet laryngoscope and via the 4-lumen jet catheter with the bleeding caudal to ventilation source. If the bleeding was cranial to the 4-lumen jet catheter ventilation, migration of blood into the lower respiratory tract was seen when reflux of blood reached the entrainment area. From this area, blood is transported within the jet stream into the lower respiratory tract. CONCLUSIONS: SHFJV protects the lower respiratory tract from blood aspiration in case of tracheal bleeding. During SHFJV via the 4-lumen jet catheter, aspiration of blood only occurs if bleeding is localized cranial to the 4-lumen jet catheter ventilation. In case of heavy tracheal bleeding, the jet sources should be positioned cranial to the site of bleeding.

Cardiovascular effects of auricular stimulation -a systematic review and meta-analysis of randomized controlled clinical trials.

Background: The number of randomized controlled trials using auricular stimulation (AS) such as transauricular vagus nerve stimulation, or other auricular electrostimulation or auricular acupuncture or acupressure, in experimental and clinical settings, has increased markedly over the last three decades. This systematic review focusses on cardiovascular effects of auricular stimulation. Methods and analysis: The following databases were searched: MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, and Scopus Database. RCTs were reviewed that had been published in English and European languages. Data collection and analysis was conducted by two reviewers independently. Quality and risk assessment of included studies was performed and the meta-analysis of the effect of the most frequently assessed biomarkers. Results: Altogether, 78 trials were included. 38 studies assessed heart rate (HR), 19 studies analyzed heart rate variability (HRV), 31 studies analyzed blood pressure (BP) and 7 studies were identified that measured oxygen saturation (O2), 2 studies on baroreflex sensitivity and 2 studies on skin conductance were evaluated in this review. 26 studies contained continuous data and were eligible for meta-analysis, 50 trials reported non continuous data and were evaluated descriptively. The overall quality of the studies was moderate to low. AS leads to a significant reduction of HR, the changes though were not considered an adverse reaction. Furthermore, when looking at HRV, AS was able to reduce the LF/HF ratio significantly compared to control procedures. No other cardiovascular parameters (blood pressure, oxygen saturation, baroreflex sensitivity) were changed significantly. AS produced only minor side effects in all trials. Conclusion: AS can lead to clinically safe reduction of HR and changes in the LF/HF ratio of the HRV, which is presumably via an increase in vagal activity. More research is needed to clarify whether AS can be used to modulate tachycardia or indications with autonomic imbalance. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=231885 PROSPERO, ID CRD42021231885.

Duration of Surgery and Intraoperative Blood Pressure Management Are Modifiable Risk Factors for Postoperative Neurocognitive Disorders After Spine Surgery: Results of the Prospective CONFESS Study.

STUDY DESIGN: Prospective quasi-experimental observational study. OBJECTIVE: The objective of this study was to evaluate whether duration of surgery is a modifiable risk factor for postoperative delirium (POD) after spine surgery and explore further modifiable risk factors. In addition, we sought to investigate the association between POD and postoperative cognitive dysfunction and persistent neurocognitive disorders. SUMMARY OF BACKGROUND DATA: Advances in spine surgery enable technically safe interventions in elderly patients with disabling spine disease. The occurrence of POD and delayed neurocognitive complications ( e.g. postoperative cognitive dysfunction/persistent neurocognitive disorder) remain a concern since these contribute to inferior functional outcomes and long-term care dependency after spine surgery. MATERIALS AND METHODS: This prospective single-center study recruited patients aged 60 years or above and scheduled for elective spine surgery between February 2018 and March 2020. Functional (Barthel Index, BI) and cognitive outcomes [Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test battery; telephone Montréal Cognitive Assessment] were assessed at baseline, three (V3), and 12 months postoperatively. The primary hypothesis was that the duration of surgery predicts POD. Multivariable predictive models of POD included surgical and anesthesiological parameters. RESULTS: Twenty-two percent of patients developed POD (n=22/99). In a multivariable model, duration of surgery [OR adj =1.61/h (95% CI, 1.20-2.30)], age [OR adj =1.22/yr (95% CI, 1.10-1.36)], and baseline deviations of intraoperative systolic blood pressure [25th percentile: OR adj =0.94/mm Hg (95% CI, 0.89-0.99); 90th percentile: OR adj =1.07/mm Hg (95% CI, 1.01-1.14)] were significantly associated with POD. Postoperative cognitive scores generally improved (V3, ΔCERAD total z -score: 0.22±0.63). However, this positive group effect was counteracted by POD [beta: -0.87 (95% CI, -1.31 to 0.42)], older age [beta: -0.03/yr (95% CI, -0.05 to 0.01)], and lack of functional improvement [ΔBI; beta: -0.04/point (95% CI, -0.06 to 0.02)]. Cognitive scores at twelve months remained inferior in the POD group, adjusted for baseline cognition/age. CONCLUSIONS: This study identified distinct neurocognitive effects after spine surgery, which are influenced by perioperative risk factors. Potential cognitive benefits are counteracted by POD, rendering its prevention critical in an aging population.

Stimulation of Lactation Using Acupuncture: A Case Study.

INTRODUCTION: Breastfeeding is a recognized preferred method of infant feeding; however, for many women, difficulties in breastfeeding result in termination before the recommended period of time. Acupuncture is suggested to be a promising option to treat lactation insufficiency and enhance the production of maternal milk. MAIN ISSUE: We have reported the case of a woman with lactation insufficiency due to Caesarean section and congenital unilateral invaginated nipple. Milk production started on the 3rd day following delivery. The newborn was not provided with any food or fluids other than mother's milk. At 5 days of life, the newborn required long feeding periods and lost 4% of his birth weight, with the participant reporting lactation insufficiency described by the perception of inadequate milk production. MANAGEMENT: Despite the implementation of conventional measures to improve lactation, the difficulties in breastfeeding persisted. Acupuncture was tried on Day 6 of life, and enhanced milk production was observed, which could be measured as the volume of residual milk extracted using the breast pump each time after the newborn achieved satiety. After acupuncture treatment there was an augmentation of maternal milk production from both breasts and successful lactation. CONCLUSION: This case study provides information that might be useful for prospective investigation of acupuncture's efficacy in women with lactation insufficiency.

Auricular stimulation for preoperative anxiety - A systematic review and meta-analysis of randomized controlled clinical trials.

STUDY OBJECTIVE: Previous randomized controlled trials (RCTs) suggest that auricular stimulation (AS) is safe and effective in treatment of preoperative anxiety; however, a systematic evaluation is lacking. The aim was to summarize the evidence on efficacy and safety of AS for preoperative anxiety, as well as for other outcomes. DESIGN: We conducted a systematic review of RCTs including patients from all available populations. The search was done through MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science and Scopus Database from inception to June 2020. Study selection and data extraction were performed in by 2 independent reviewers with ability to resolve disagreements by a third author. Meta-analyses as well as the risk of bias and evidence quality assessments were performed according to the Cochrane 6.2, 2021 handbook recommendations. INTERVENTIONS: We compared AS with pharmacological and non-pharmacological interventions for different outcomes. MEASUREMENTS: We assessed the repercussion of the evaluated interventions over anxiety scores and their safety, physiological parameters, perioperative medications requirement and intensity of postoperative pain. MAIN RESULTS: We have included 15 studies with 1603 patients. AS has presented reduced anxiety scores as compared to the sham control (Standardized Mean Difference (SMD) -0.72, 95% confidence interval (CI) -1.09 to -0.36, p < 0.0001; 8 trials; 701 patients; heterogeneity: I2 80%; GRADE: moderate certainty) and to no intervention (SMD -1.01, 95% CI -1.58 to -0.45, p = 0.0004; 4 trials; 420 patients; heterogeneity: I2 84%; GRADE: very low certainty). There was no difference between AS and benzodiazepines (SMD -0.03; 95% CI: -0.34 to 0.28; p = 0.84; 3 trials; 158 patients; heterogeneity: I2 0%; GRADE: very low certainty). No trials reported serious adverse effects of AS. CONCLUSIONS: AS may be useful in treatment of preoperative anxiety. Due to heterogenous certainty in effect estimates, further research is needed to clarify the actual efficacy of AS for preoperative anxiety.

Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial.

IMPORTANCE: A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements. OBJECTIVE: To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone. DESIGN, SETTING, AND PARTICIPANTS: This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019. INTERVENTIONS: In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles. MAIN OUTCOMES AND MEASURES: The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain. RESULTS: A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups. CONCLUSIONS AND RELEVANCE: Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02364167.

Evidence for a modulating effect of transcutaneous auricular vagus nerve stimulation (taVNS) on salivary alpha-amylase as indirect noradrenergic marker: A pooled mega-analysis.

BACKGROUND: Non-invasive transcutaneous auricular vagus nerve stimulation (taVNS) has received tremendous attention as a potential neuromodulator of cognitive and affective functions, which likely exerts its effects via activation of the locus coeruleus-noradrenaline (LC-NA) system. Reliable effects of taVNS on markers of LC-NA system activity, however, have not been demonstrated yet. METHODS: The aim of the present study was to overcome previous limitations by pooling raw data from a large sample of ten taVNS studies (371 healthy participants) that collected salivary alpha-amylase (sAA) as a potential marker of central NA release. RESULTS: While a meta-analytic approach using summary statistics did not yield any significant effects, linear mixed model analyses showed that afferent stimulation of the vagus nerve via taVNS increased sAA levels compared to sham stimulation (b = 0.16, SE = 0.05, p = 0.001). When considering potential confounders of sAA, we further replicated previous findings on the diurnal trajectory of sAA activity. CONCLUSION(S): Vagal activation via taVNS increases sAA release compared to sham stimulation, which likely substantiates the assumption that taVNS triggers NA release. Moreover, our results highlight the benefits of data pooling and data sharing in order to allow stronger conclusions in research.

Goal-directed acupuncture in sports-placebo or doping?

The modern pentathlon (MP), sports discipline including fencing, swimming, steeplechase and a cross-country run, requires a rapid change of central nervous and peripheral neuromuscular activity from one sport to another in order to achieve the best possible results. We describe the case where a top MP athlete was supported by a program of acupoint stimulation, which was directed to relieve the symptoms, preventing him from effective performance. Although the fact of acupoint stimulation was associated with improvement of his results, other factors like training effect, placebo and nonspecific physiological effects and their mechanisms in sports are discussed in a literature review. The popularity of complementary and alternative medicine methods among the athletes raises the question of their potential misuse as a doping in competitive sports.

Automated Chest Compression Allows Sufficient Resuscitation During Computed Tomography to Reveal the Cause of In-hospital Cardiac Arrest-A Case Report.

Computed tomography (CT) may be used to determine the reversible causes of in-hospital cardiac arrest (IHCA), while the automated chest compression devices (ACCDs) might be helpful to maintain sufficient circulation in x-ray environment during CT. We describe a case, where ACCD was used for continuous cardiopulmonary resuscitation during the CT procedure in an 82-year-old patient with IHCA of unknown cause. Artifact-free CT helped to identify the retroperitoneal hemorrhage as a cause of IHCA, which could not be identified using bedside diagnostics. This observation suggests ACCDs as a helpful adjunct for cardiopulmonary resuscitation in patients undergoing CT diagnostics of IHCA.